Chapter 60: Infections in Children with Neurologic Impairment

DEFINITIONS

Neurologic impairment (NI) encompasses a variety of static and progressive neurologic diseases that involve the central and/or peripheral nervous systems and result in functional and/or intellecutual impairments.¹ NI includes but is not exclusive to children with hypoxic−ischemic encaphlopathy, genetic or metabolic disorders, brain or spinal cord malformations, spinal muscular atrophy, and muscular dystrophies. The health impact of NI extends well beyond the neurologic system. Chronic respiratory and skin and/or soft tissue problems are common in children with NI. These problems can increase the children’s susceptibility to infections. This chapter focuses on common respiratory and skin infections in children with NI. Please see Chapters 74 (on cerebrospinal fluid shunt infections) and 75 (on central venous cather-associated bloodstream infections) for other types of infections associated with NI.

RESPIRATORY INFECTIONS

Oromotor dysfunction, gastroesophageal reflux, impaired cough, central hypoventilation, bronchial hyperreactivity, and respiratory muscle weakness may contribute to children with NI’s vulnerability to respiratory infections.²⁻⁵ Acute respiratory infections are among the most common reasons for hospitalization, intensive care unit (ICU) admission, and death in children with NI.^4,6,7

Relevant to the etiology of many respiratory infections in children with NI, tracheotomy is one of the most common surgical procedures performed in this population. Approximately 5000 children in the United States undergo tracheotomy each year.⁸ Historically, tracheotomy was predominately performed for older children with acute upper aiway compromise due to infections (e.g., epiglottitis and croup).⁹ With changes in both infectious disease epidemiology and the survival of infants born prematurely or with chronic underlying disease (e.g., neuromuscular disease, congential anomalies), tracheotomy is now more commonly performed for long-term mechanical ventilation in patients with NI.⁹⁻¹²

BACTERIAL PNEUMONIA IN CHILDREN WITH NEUROLOGIC IMPAIRMENT

Definitions and Epidemiology

Pneumonia is any infection of the lower airways. Children with NI are suspectible to pneumonia from exogenous sources (e.g., community-acquired viral or bacterial pneumonia) and endogenous sources (e.g., aspiration of saliva or gastric contents). In children with NI, pneumonia is one of the most common reasons for hospitalization, admission to an ICU, and death.^1,4,13 Children with NI are at five- to seven-fold greater risk for hosptailzation from respiratory infection than otherwise healthy children.⁷

Children with tracheostomy or ventilator dependence are at further increased risk for pneumonia. Of all patients with tracheotomy, 88% will develop a lower airway infection within one year of tracheotomy placement. Children with tracheotomy have an average of 2.8 episodes of pneumonia annually.¹⁴

Pathogenesis

Children with NI are at increased risk for developing both community- and hospital-acquired pneumonia due to difficulties with bacterial clearance from the airway. Respiratory muscle weakness and impaired or absent cough reflex prevent adequate expulsion of respiratory secretions and infectious pathogens.

Children with NI are ...